The ultimate goal of this study is to elucidate the molecular mechanisms of uterine leiomyoma (UL) formation and growth, and identify potential targets for novel therapeutic and preventive treatments of this disease. UL is a benign tumor of the myometrium that affects millions of reproductive-age women. Surgical removal of the entire uterus (hysterectomy) is the primary treatment option, and management of UL puts an enormous burden on the healthcare system. Therefore, finding a new therapeutic treatment replacing surgery is of great interest to the public. Due to the absence of a proper research model system reflecting characteristics of the original tumors, the biological nature and the causes of UL are poorly understood. Although growth dependency of UL on ovarian steroids (172-estradiol and progesterone) is well established, the relative importance and function of 172-estradiol and progesterone are yet to be clarified. In spite of accumulating evidence for the essential role of progesterone in UL growth, no research model has clearly demonstrated a growth-promoting effect of progesterone on UL. To elucidate the function of ovarian steroids in UL, we have established a novel xenograft model in which tissue fragments of human leiomyoma were grafted beneath the renal capsule of immunodeficient mice. The size of the leiomyoma xenografts increased in response to 172- estradiol and progesterone as demonstrated by cell proliferation and accumulation of extra-cellular matrix. In contrast, xenograft growth induced by 172-estradiol and progesterone was blocked by the anti-progestin RU486, indicating the essential role of progesterone and progesterone receptor (PR) in leiomyoma tumor growth. Previously, 172-estradiol has been thought to be the primary stimulus for UL growth. Surprisingly, 172-estradiol by itself neither increased nor maintained tumor size. Likewise, progesterone alone did not affect UL growth in this model. Although not mitogenic, 172-estradiol was required for expression of PR, and was essential for progesterone to act on UL xenografts. Our study clearly demonstrates the pivotal role of progesterone in growth and maintenance of UL. The results of our xenograft model agree with clinical observations, yet radically change the paradigm of steroid hormone-regulated human UL growth by emphasizing the importance of progesterone instead of 172- estradiol. Using the novel xenograft model, we will elucidate the cellular and molecular mechanisms of human UL tumor growth controlled by 172-estradiol and progesterone. PUBLIC HEALTH RELEVANCE: A better understanding of how uterine leiomyomata grow is essential to developing novel therapies for this tumor. While the dependency of uterine leiomyoma on ovarian steroids is well established, the relative importance and function of 172-estradiol versus progesterone are yet to be clarified. Recently, we developed a method of growing human uterine leiomyoma tumors in immunodeficient mice. The xenografts of human uterine leiomyoma faithfully preserved the phenotype and hormone responsiveness of original human tumors in situ, and their growth was totally dependent on progesterone and 172-estradiol. Using this novel xenograft model in combination with viral gene transduction, we will elucidate the cellular and molecular mechanisms of human uterine leiomyoma growth.